Home Nutritional Support (Total Parenteral/Enteral Nutrition)
Total parenteral nutrition (TPN), also known as parenteral hyperalimentation, is used for individuals with medical conditions that impair gastrointestinal absorption to a degree incompatible with life. It is also used for variable periods of time to bolster the nutritional status of severely malnourished individuals with medical or surgical conditions. TPN involves percutaneous transvenous implantation of a central venous catheter into the vena cava or right atrium. A nutritionally adequate hypertonic solution consisting of glucose, amino acids, electrolytes, vitamins, and minerals and sometimes fats, is administered daily. An infusion pump is generally used to assure a steady flow of the solution either on a continuous (24-hour) or intermittent schedule. The catheter is kept patent between infusions.Enteral nutrition (EN) is used for individuals with a functional gastrointestinal tract, but with disorders of the pharynx, esophagus, or stomach that prevent the intake of adequate nutrients. EN involves administering non-sterile liquids directly into the gastrointestinal tract through a nasogastric, gastrostomy or jejunostomy tubes. An infusion pump may be used to assist the flow of liquids. Feedings may be intermittent or continuous (infused 24 hours a day).
Home nutritional support is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Home nutritional support (total parenteral nutrition/enteral nutrition) for the treatment of other conditions/diseases, including, but not limited to dementia, is considered investigational.
The use of in-line cartridges containing digestive enzymes (e.g., Relizorb) for individuals receiving enteral feeding is considered investigational.
Home nutritional support is considered medically appropriate if ANY ONE of the following criteria are met:
Enteral nutrition (EN) for individuals with ALL of the following:
Functioning GI tract of sufficient length and conditions to allow adequate nutritional absorption
At risk of malnutrition as indicated by ANY ONE of the following:
Anatomical inability to swallow, (such as head and neck cancer or an obstructing tumor or stricture of the esophagus or stomach)
Increased nutritional requirements (such as burns, cystic fibrosis)
Neuromuscular swallowing disorder (such as stroke, gastroparesis, motor neuron disease, multiple sclerosis)
Central nervous system disorder leading to sufficient interference with the neuromuscular coordination of chewing and swallowing that a risk of aspiration exists
Pre-operatively for malnourished individual undergoing major abdominal procedure
Palliation of chronic malignant gastrointestinal obstruction
Mild to moderate malabsorption
Physiologic anorexia (such as cancer, sepsis, liver disease, HIV/AIDS)
Total parenteral nutrition (TPN) for individuals with ALL of the following:
Unable to benefit from tube feedings due to severe pathology of the alimentary tract that does not allow absorption of sufficient nutrients
At risk of malnutrition as indicated by ANY ONE of the following conditions:
Non-functional, inaccessible or perforated gastrointestinal tract
Inflammatory bowel disease
Hyperemesis gravidarum after failed medical management
Protein losing enteropathy
Obstruction secondary to stricture or neoplasm of the esophagus or stomach
Short bowel syndrome secondary to massive small bowel resection
Malabsorption due to enterocolic, enterovesical or enterocutaneous fistulas
Motility disorder (pseudo-obstruction)
Prolonged paralytic ileus following a major surgical procedure or multiple injuries
Newborn infants with catastrophic gastrointestinal anomalies such as tracheoesophageal fistulas, gastroschisis, omphalocele or massive intestinal atresia
Infants and young children who fail to thrive due to systemic disease or secondary to intestinal insufficiency associated with short bowel syndrome, malabsorption or chronic idiopathic diarrhea
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
Hyperalimentation may be provided safely in the home. Generally, a daily caloric intake of 2000-2200 calories for adults is sufficient to maintain body weight. Energy expenditure should be assessed throughout illness for children to determine sufficient energy requirements and avoid under- or over-estimating of requirements.
American Academy of Pediatrics. (2016). Clinical practice guidelines from the cystic fibrosis foundation for preschoolers with cystic fibrosis. Retrieved July 11, 2017 from https://www.aap.org.
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). (2002). Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Retrieved July 12, 2017 from http://pen.sagepub.com.
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). (2011). Nutrition screening, assessment, and intervention in adults. Retrieved April 22, 2011 from http://www.nutritioncare.org.
American Society for Parenteral and Enteral Nutrition (ASPEN). (2009). ASPEN clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. Retrieved June 11, 2018 from https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Clinical_Guidelines/.
Berry, A.J. (2014). Pancreatic enzyme replacement therapy during pancreatic insufficiency. Nutrition in Clinical Practice, DOI: 10.1177/0884533614527773. (Level 5 evidence)
Centers for Medicare & Medicaid Services. CMS.gov. NCD for enteral and parenteral nutritional therapy (180.2). Retrieved March 28, 2017 from https://www.cms.gov.
Cystic Fibrosis Foundation. (2016). Enteral tube feeding for individuals with cystic fibrosis. Retrieved July 3, 2018 from www.cff.org.
European Society for Clinical Nutrition and Metabolism (ESPEN). (2005). ESPEN guidelines on artificial enteral nutrition – percutaneous endoscopic gastrostomy (PEG). Retrieved June 11, 2018 from http://espen.info/documents/PEG.pdf.
Freedman, S., Orenstein, D., Black, P, Brown, P., McCoy, K., Stevens, J., et al. (2017). Increased fat absorption from enteral formula through an in-line digestive cartridge in patients with cystic fibrosis. JPGN, 65 (1), 97 -101. (Level 2 evidence)
Miller, C & Madhoun, L. (2016). Feeding and swallowing issues in infants with craniofacial anomalies. American Speech-Language-Hearing Association, 5 (1), 13-26. (Level 5 evidence)
National Institute of Health and Clinical Excellence. (2006). Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Retrieved May 6, 2016 from www.nice.org.uk.
Pironi, L., Arends, J., Bozzetti, F., Cuerda, C., Gillanders, L., Jeppesen, P., et al. (2016). ESPEN guidelines on chronic intestinal failure in adults. Clinical Nutrition, 35 (2), 247-307. Abstract retrieved March 28, 2017 from PubMed database.
Winifred S. Hayes, Inc. Search & Summary. (2017, August). Relizorb (Alcresta Therapeutics Inc.). Retrieved September 5, 2017 from www.Hayesinc.com/subscribers).
ORIGINAL EFFECTIVE DATE: 5/4/1982
MOST RECENT REVIEW DATE: 10/24/2018
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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